Anaphylaxis Action Plan - Roseville Area Schools

Name:
ALLERGIC to:
Anaphylaxis Action Plan
For those requiring emergency EPINEPHRINE treatment
“Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death.”
(National Institute of Allergy & Infectious Disease, 2010)
DOB:
Photo
History of Asthma: £ Yes (more at risk for severe reaction) £ No
May self-carry medications: £ Yes £ No
May self administer medications: £ Yes £ No
Medication Doses
EPINEPHRINE Dose:
Up to 55 lbs. (25 kg)
£ EpiPen Jr. (0.15 mg)
£ Adrenaclick (0.15 mg)
£ Twinject (0.15 mg)
Over 55 lbs. (25 kg)
£ EpiPen (0.3 mg)
£ Adrenaclick (0.3 mg)
£ Twinject (0.3 mg)
*Antihistamine Type + Dose:
£ Benadryl (also known as Diphenhydramine)
£ 12.5 mg (1 teaspoon or 1 chewable)
£ 25 mg (2 teaspoons or 2 chewables)
£ 50 mg (4 teaspoons or 4 chewables)
£ Other antihistamine:
Extremely reactive to the following foods:
THEREFORE:
£ If checked, give EPINEPHRINE immediately for ANY symptoms if the allergen was likely eaten.
£ If checked, give EPINEPHRINE immediately if the allergen was definitely eaten, even if no symptoms are noted.
Any SEVERE SYMPTOMS after suspected or known
ingestion:
One or more of the following:
Lung: Short of breath, wheeze, repetitive cough
Heart: Pale, blue, faint, weak pulse, dizzy, confused
Throat: Tight, hoarse, trouble breathing/swallowing
Mouth: Obstructive swelling (tongue and/or lips)
Skin: Many hives over body
Or combination of symptoms from different body areas:
Skin: Hives, itchy rashes, swelling (eyes, lips)
Gut: Vomiting, crampy pain
1. INJECT EPINEPHRINE
IMMEDIATELY
2. Call 911
3. Begin monitoring (as specified below)
4. Give additional medications:*
• Antihistamine
• Inhaler (bronchodilator) if asthma
*Antihistamines & inhalers/bronchodilators
are not to be depended upon to treat
severe reaction (anaphylaxis). USE
EPINEPHRINE.
MILD SYMPTOMS only:
Mouth: Itchy Mouth
Skin: A few hives around mouth/face, mild itch
Gut: Mild nausea/discomfort
1. GIVE ANTIHISTAMINE
2. Stay with student; alert healthcare
professionals and parent/guardian
3. If symptoms progress (see above) USE
EPINEPHRINE
4. Begin monitoring (as specified below)
For unique situations:
Monitoring
A SECOND DOSE of EPINEPHRINE can be given 5 minutes or more after the first if symptoms persist or recur.
Stay with person; alert healthcare professionals and parent/guardian. Tell rescue squad EPINEPHRINE was given.
Note time when EPINEPHRINE was administered. For a severe reaction, consider keeping person lying on back with legs raised.
Treat person even if parents cannot be reached. See back/attached for auto-injection technique.
Provider Signature:
Printed Name:
Parent/Guardian Signature:
Page 1: Patient
Page 2: School/Daycare/Work
Page 3: Chart
Phone
Phone
Date
Date
Turn Form Over →
Adapted from the Food Allergy &
Anaphylaxis Network (FAAN) Action Plan
www.foodallergy.org

EPIPEN® Auto-Injector and
EPIPEN Jr® Auto-Injector Directions
Twinject® 0.3 mg and
Twinject® 0.15 mg Directions
• First, remove the EPIPEN Auto-Injector from
the plastic carrying case
• Pull off the blue safety release cap
• Hold orange tip near outer thigh
(always apply to thigh)
Remove caps labeled “1” and “2”.
Place rounded tip against outer
thigh, press down hard until needle
penetrates. Hold for 10 seconds,
then remove.
SECOND DOSE ADMINISTRATION:
If symptoms don’t improve after 10
minutes, administer second dose:
• Swing and firmly push orange tip against
outer thigh. Hold on thigh for approximately
10 seconds.
Remove the EPIPEN Auto-Injector and
massage the area for 10 more seconds
Unscrew rounded tip. Pull syringe from
barrel by holding collar at needle base.
Slide yellow collar off plunger.
Put needle into thigh through skin,
push plunger down all the way
and remove.
DEY® and the DEY logo, EpiPen®, EpiPen 2-Pak®, and EpiPen Jr 2-Pak are registered
trademarks of Dey Pharma, L.P.
Adrenaclick 0.3 mg and
Adrenaclick 0.15 mg Directions
Remove GREY caps labeled “1” and “2”.
Place RED rounded tip against
outer thigh, press down hard
until needle penetrates. Hold
for 10 seconds, then remove.
A food allergy response kit should contain
at least two doses of epinephrine, other
medications as noted by the student’s
physician, and a copy of this Food Allergy
Action Plan.
A kit must accompany the student if
he/she is off school grounds (i.e., field
trip).
Contacts
Call 911 (Rescue squad: ) Doctor: Phone:
Parent/Guardian:
Phone:
Other Emergency Contacts
Name/Relationship:
Name/Relationship:
Phone:
Phone:
Revised 6/2011
Adapted from the Food Allergy &
Anaphylaxis Network (FAAN) Action Plan
www.foodallergy.org